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Background: Continuous arterial blood pressure (ABP) is typically recorded by placement of an intraarterial catheter. Recently, noninvasive ABP monitors have been shown to be comparable in accuracy to invasive measurements. In a previous study, we showed that the fluctuations in beat-to-beat ABP measurements were not random variations but had a complex dynamical structure, and that ABP dynamical complexity was inversely associated with surgical risk estimated using the Society of Thoracic Surgeons (STS) index. Dynamical complexity is a mathematical construct that reflects the capacity of a physiological system to adapt to stimuli. The objectives of present study were to: (1) determine whether noninvasive beat-to-beat ABP measurements also exhibit a complex temporal structure; (2) compare the complexity of noninvasive versus invasive ABP time series; and (3) quantify the relationship between the complexity of noninvasive ABP time series and the STS risk scores., Methods: Fifteen adult patients undergoing coronary artery bypass graft, valve, or combined coronary artery bypass graft/valve surgery were enrolled in this observational study. Preoperative ABP waveforms were simultaneously recorded for ≥15 minutes using a radial artery catheter (invasive) and a continuous noninvasive arterial pressure monitor. Beat-to-beat systolic blood pressure (SBP), diastolic blood pressure (DBP), pulse pressure (PP), and mean arterial pressure (MAP) time series were extracted from the continuous waveforms. Complexity was assessed using the multiscale entropy method. The Wilcoxon signed-rank test was used to compare the mean ranks of indices derived from invasive versus noninvasive ABP time series. Spearman correlation coefficients were used to quantify the relationship between invasive and noninvasive indices. Linear regression analysis was used to quantify the association between each of the complexity indices and the STS risk scores., Results: Beat-to-beat fluctuations in noninvasive ABP measurements were not random but complex; however, their degree of complexity was lower than that of fluctuations in invasively obtained ABP signals (SBP: 7.05 vs 8.66, P < .001; DBP: 7.40 vs 8.41, P < .001; PP: 6.83 vs 8.82, P < .001; and MAP: 7.17 vs 8.68, P < .005). Invasive and noninvasive indices for MSEΣ·slope showed good correlation (rs) (0.53 for SBP, 0.79 for DBP, 0.42 for PP, 0.60 for MAP). The complexity of noninvasive ABP time series (-0.70 [-1.28 to -0.11]; P = .023 for DBP), like that of invasive time series (-0.94 [-1.52 to -0.35]; P = .004 for DBP), was inversely associated with estimated surgical risk in patients undergoing cardiovascular operations., Conclusions: Our results support the use of noninvasive ABP monitoring in computations of complexity-based indices that correlate with estimated surgical risk.

Purpose of Review: Guidelines for enhanced recovery after surgery (ERAS) have recently been published for lung surgery. Although some of the recommendations are generic or focused on anesthetic and nursing care, other recommendations are more specific to a thoracic surgeon's practice. The present review concentrates on the surgical approach, optimal chest drain management, and the importance of early mobilization., Recent Findings: Most lung cancer resections are still performed via an open thoracotomy approach. If a thoracotomy is to be used, a muscle-sparing approach may result in reduced pain and better postoperative function. Sparing of the intercostal bundle also reduces pain. There is now evidence that minimally invasive surgery for early lung cancer results in superior patient outcomes. Postoperatively, single chest tubes should be used without the routine application of external suction. Digital drainage systems are more reliable and may produce superior outcomes. Conservative chest drain removal policies are unnecessary and impair patient recovery. Early mobilization protocols should be instigated to reduce postoperative complications., Summary: The use of ERAS after lung surgery has the potential to improve patient outcomes. Although specific surgical elements are in the minority, thoracic surgeons should be involved in all aspects of perioperative care as part of the wider multidisciplinary team.

Purpose of Review: Enhanced Recovery After Thoracic Surgery (ERATS) has gained momentum over the past few years, although the evidence base and expert recommendations lag behind other specialties. This review will present and examine key points from the first guidelines for enhanced recovery after lung surgery, released in 2018, jointly sponsored by the European Society of Thoracic Surgeons and the Enhanced Recovery After Surgery Society., Recent Findings: The recently released guidelines present core components of enhanced recovery as they pertain to lung resection surgery. Although evidence is still sparse in some areas, the guidelines summarize the available literature and incorporate levels of recommendation based upon the strength of available data as well as expert consensus. As of yet, the relative contribution of individual ERATS components to improvement in outcomes is unclear, but overall compliance does seem to be linked to positive results. Since the creation of the guidelines, additional literature related to ERATS has been released, and it will be incorporated and discussed into our review., Summary: The creation of guidelines for enhanced recovery after lung resection will provide the thoracic anesthesiologist a framework upon which to build a comprehensive perioperative anesthetic plan.

Pharmacists' role may be ideal for improving rationality of drug prescribing practice. We aimed to study the impact of multifaceted pharmacist interventions on antibiotic prophylaxis in patients undergoing clean or clean-contaminated operations in cardiothoracic department. A pre-test-post-test quasiexperimental study was conducted in a cardiothoracic ward at a tertiary teaching hospital in Suzhou, China. Patients admitted to the ward were collected as baseline group (2011.7-2012.12) and intervention group (2013.7-2014.12), respectively. The criteria of prophylaxis antibiotic utilization were established on the basis of the published guidelines and official documents. During the intervention phase, a dedicated pharmacist was assigned and multifaceted interventions were implemented in the ward. Then we compared the differences in antibiotic utilization, bacterial resistance, clinical and economic outcomes between the 2 groups. Furthermore, patients were collected after the intervention (2015.1-2015.6) to evaluate the sustained effects of pharmacist interventions. 412 and 551 patients were included in the baseline and intervention groups, while 156 patients in postintervention group, respectively. Compared with baseline group, a significant increase was found in the proportion of antibiotic prophylaxis, the proportion of rational antibiotic selection, the proportion of suitable prophylactic antibiotic duration, and the proportion of suitable timing of administration of the first preoperative dose (P < 0.001). Meanwhile, a significant reduction was seen in the rate of unnecessary replacement of antibiotics and the rate of unnecessary combinations (P < 0.001). Besides, pharmacist intervention resulted in favorable outcomes with significantly decreased rates of surgical site infections, prophylactic antibiotic cost, and significantly shortened length of stay (P < 0.05). Furthermore, there were also significant decreases of the rates of antibiotic resistant enterobacter cloacae, klebsiella pneumonia, and staphylococcus aureus (P < 0.05). Moreover, the effects were sustained after discontinuation of the active interventions, as shown in prophylactic antibiotic utilization data. Pharmacist interventions in cardiothoracic surgery result in a high adherence to evidence-based treatment guidelines and a profound culture change in drug prescribing with favorable outcomes. The effects of pharmacist intervention are sustained and the role of pharmacists is emphasized for rational medication and optimal outcomes in clinical treatment.

Background: With the availability of transcatheter aortic valve replacement, management of coronary artery disease in patients with severe aortic stenosis (AS) is posing challenges. Outcomes of percutaneous coronary intervention (PCI) in patients with severe AS and coronary artery disease remain unknown. We sought to compare the short-term outcomes of PCI in patients with and without AS., Methods and Results: From our PCI database, we identified 254 patients with severe AS who underwent PCI between 1998 and 2008. Using propensity matching, we found 508 patients without AS who underwent PCI in the same period. The primary end point of 30-day mortality after PCI was similar in patients with and without severe AS (4.3% [11 of 254] versus 4.7% [24 of 508]; hazard ratio, 0.93; 95% confidence interval, 0.51-1.69; P=0.2). Patients with low ejection fraction (≤30%) and severe AS had a higher 30-day post-PCI mortality compared with those with an ejection fraction >30% (5.4% [7 of 45] versus 1.2% [4 of 209]; P<0.001). In addition, AS patients with high Society of Thoracic Surgeons score (≥10) had a higher 30-day post-PCI mortality than those with a Society of Thoracic Surgeons score <10 (10.4% [10 of 96] versus 0%; P<0.001)., Conclusions: PCI can be performed in patients with severe symptomatic AS and coronary artery disease without an increased risk of short-term mortality compared with propensity-matched patients without AS. Patients with ejection fraction ≤30% and Society of Thoracic Surgeons score ≥10% are at a highest risk of 30-day mortality after PCI. This finding has significant implications in the management of severe coronary artery disease in high-risk severe symptomatic AS patients being considered for transcatheter aortic valve replacement.

Background: Studies that are the basis of recommended volume thresholds for CABG surgery are outdated and not reflective of recent advances in the field. This study examines both hospital and surgeon volume-mortality relations for CABG surgery through the use of a population-based clinical data set., Methods and Results: Data from New York's clinical CABG surgery registry from 1997 to 1999 (total number of procedures, 57 150) were used to examine the individual and combined impact of annual hospital volume and annual surgeon volume on in-hospital mortality rates after adjusting for differences in severity of illness. Significantly lower risk-adjusted mortality rates occurred above all annual hospital volume thresholds between 200 and 800 and above all surgeon volume thresholds between 50 and 200. The number needed to treat (NNT) at higher-volume providers to avoid a death was minimized for a hospital threshold volume of 100 (NNT=50) and a surgeon threshold volume of 50 (NNT=118). The risk-adjusted mortality rate (RAMR) for patients undergoing surgery performed by surgeons with volumes of > or =125 in hospitals with volumes of > or =600 was 1.89%. The RAMR was significantly higher (2.67%) for patients undergoing surgery performed by surgeons with volumes of <125 in hospitals with volumes of <600., Conclusions: Higher-volume surgeons and hospitals continue to have lower risk-adjusted mortality rates, and patients undergoing surgery performed by higher-volume surgeons in higher-volume hospitals have the lowest mortality rates.

Background: An inverse relation exists between the number of coronary angioplasty procedures performed by physicians or hospitals and short-term mortality. It is not known, however, whether a similar relation holds for physicians and hospitals that perform primary angioplasty for acute myocardial infarction., Methods and Results: We analyzed data from the 1995 New York State Coronary Angioplasty Reporting System Registry to determine the relation between the number of primary angioplasty procedures performed by physicians and hospitals and in-hospital mortality. Patients who underwent angioplasty procedures within 23 hours of onset of acute myocardial infarction without preceding thrombolytic therapy were included (n=1342). In-hospital mortality was reduced 57% among patients who underwent primary angioplasty by high-volume as opposed to low-volume physicians (adjusted relative risk 0.43; 95% CI 0.21 to 0.83). When patients with acute myocardial infarction were treated with primary angioplasty in high-volume hospitals rather than low-volume institutions, the relative risk reduction for in-hospital mortality was 44% (adjusted relative risk 0.56; 95% CI 0.29 to 1.1). Compared with patients treated at low-volume hospitals by low-volume physicians, patients treated at high-volume hospitals by high-volume physicians had a 49% reduction in the risk of in-hospital mortality (adjusted relative risk 0.51; 95% CI 0.26 to 0.99)., Conclusions: Among hospitals in New York State, a higher volume of primary angioplasty procedures performed by physicians and/or hospitals was associated with a lower mortality rate.

Objective: To review the Department of Veteran Affairs (VA) and the Society of Thoracic Surgeons (STS) national databases over the past 10 years to evaluate their relative similarities and differences, to appraise their use as quality improvement tools, and to assess their potential to facilitate improvements in quality of cardiac surgical care., Summary Background Data: The VA developed a mandatory risk-adjusted database in 1987 to monitor outcomes of cardiac surgery at all VA medical centers. In 1989 the STS developed a voluntary risk-adjusted database to help members assess quality and outcomes in their individual programs and to facilitate improvements in quality of care., Methods: A short data form on every veteran operated on at each VA medical center is completed and transmitted electronically for analysis of unadjusted and risk-adjusted death and complications, as well as length of stay. Masked, confidential semiannual reports are then distributed to each program's clinical team and the associated administrator. These reports are also reviewed by a national quality oversight committee. Thus, VA data are used both locally for quality improvement and at the national level with quality surveillance. The STS dataset (217 core fields and 255 extended fields) is transmitted for each patient semiannually to the Duke Clinical Research Institute (DCRI) for warehousing, analysis, and distribution. Site-specific reports are produced with regional and national aggregate comparisons for unadjusted and adjusted surgical deaths and complications, as well as length of stay for coronary artery bypass grafting (CABG), valvular procedures, and valvular/CABG procedures. Both databases use the logistic regression modeling approach. Data for key processes of care are also captured in both databases. Research projects are frequently carried out using each database., Results: More than 74,000 and 1.6 million cardiac surgical patients have been entered into the VA and STS databases, respectively. Risk factors that predict surgical death for CABG are very similar in the two databases, as are the odds ratios for most of the risk factors. One major difference is that the VA is 99% male, the STS 71% male. Both databases have shown a significant reduction in the risk-adjusted surgical death rate during the past decade despite the fact that patients have presented with an increased risk factor profile. The ratio of observed to expected deaths decreased from 1.05 to 0.9 for the VA and from 1.5 to 0.9 for the STS., Conclusion: It appears that the routine feedback of risk-adjusted data on local performance provided by these programs heightens awareness and leads to self-examination and self-assessment, which in turn improves quality and outcomes. This general quality improvement template should be considered for application in other settings beyond cardiac surgery.

Objectives: The relation of physician performance to physician training and experience is not well understood. The aim of this study was to examine whether indicators of physician background and experience were associated with an objective measure of physician performance., Methods: Physician background information obtained from the Directory of Board-Certified Medical Specialists was linked to physician risk-adjusted mortality rates obtained from three statewide data bases of coronary artery bypass surgeons. Subjects were 275 surgeons who performed CABG surgery on 83,547 patients during the years 1989 to 1992. Surgical performance was measured by the mortality ratio (MR), the ratio of the observed to the predicted patient mortality rate as determined by detailed clinical information. Training institutions and physicians were characterized as prestigious if they were listed as outstanding in published articles., Results: Surgical performance was not associated with graduation from an American medical school; attendance at a prestigious medical school, residency, or fellowship program; or an academic appointment. Mortality ratios decreased with increased volume and increased with years of experience, age, and academic rank. Surgeons were more likely to be considered a "best doctor" if they had more years experience and trained at a prestigious residency or fellowship program., Conclusions: Training at a prestigious institution was associated with identification as a "best" doctor but not with lower mortality ratios.

Objectives: Despite the popularity of risk-adjusted outcomes as quality of health care indicators, their instability with time and their inability to provide reliable comparisons of small volume providers have raised questions about the feasibility and credibility of using these measures. In this article the authors describe a new analytic strategy to address these problems by examining risk-adjusted mortality with time, "Time Series Monitors of Outcome" (TSMO), and its application to cardiac surgery performed throughout the Department of Veterans Affairs between April 1987 and September 1992., Methods: Expected operative mortality for 24,029 patients undergoing coronary artery bypass surgery at all 43 centers performing this procedure was estimated using a logistic regression model to adjust for patient-specific risk factors. The ratio of observed-to-expected operative mortality was calculated for each hospital for each of the 11 6-month periods. Poisson regression models were used to identify high and low outlier hospitals based on significant deviation from the 5.5 year overall mean and/or the individual hospital's trend of observed-to-expected ratios with time., Results: This method identified four high and one low outlier hospitals based on significant deviations from the overall mean and three upward and seven downward trending outlier hospitals based on significant deviations in trend with time. A significant downward trend in observed-to-expected ratios of 4% per year also was observed for all coronary artery bypass graft procedures performed throughout the Department of Veterans Affairs during the last 5.5 year period., Conclusions: Time Series Monitors of Outcome should help reduce misclassification of outliers due to random variation in outcomes as well as provide more reliable comparative information from which to evaluate provider performance.

Restrictions on the operative domain of general surgeons threaten the viability of trauma surgery as a career choice. Our study hypothesis is that an experienced trauma surgeon can provide definitive care for life-threatening thoracic trauma. This analysis is based on clinical outcomes at an ACS-verified level I center in which there are more than 3000 trauma admissions managed annually under the direction of four academic trauma surgeons. We selected penetrating cardiac wounds and blunt tears of the thoracic aorta because these injuries are managed exclusively by the trauma service and the endpoints are distinct. During the past 4 years, 40 patients with cardiac wounds were delivered to the ED; 23 patients arrived dead. In the remaining 17, injury mechanisms were 15 stab wounds (SW), one gunshot wound (GSW), and one shotgun (SGW). Four of these patients required ED thoracotomy, and the remaining 13 underwent some form of prethoracotomy pericardial decompression. Survival rate without neurologic deficit was 94% (16 of 17). During this same period, 19 patients with a torn thoracic aorta from blunt injuries arrived with signs of life. In this group the injury mechanisms were automobile crash in 15, and the mean ISS was 39.7 +/- 2.3. One patient was transferred for total cardiopulmonary bypass; 17 of the remaining patients underwent aortic repair employing partial left heart bypass. Sixteen of our 18 patients lived and none developed paraplegia. In summary, excluding patients who arrived dead, survival for penetrating cardiac wounds was 94% and for blunt thoracic aortic tears 89%. In conclusion, these data support our contention that trauma surgeons can render definitive care for thoracic injuries with survival rates comparable to those reported by cardiothoracic surgeons.

The indiscriminate application of thoracotomy in the resuscitation of trauma has recently been challenged. Since 1 May 1974 400 consecutive trauma patients have undergone resuscitative thoracotomy in our Emergency Departments (ED). The mechanism of injury was blunt in 195 (49%) patients, gunshot wound in 147 (37%), and stab wound in 58 (14%) Upon arrival in the ED, 352 (88%) patients had no obtainable blood pressure (BP), 334 (84%), fixed pupils, and 315 (798%) failed to exhibit agonal respirations or other waning signs of life. One hundred six (27%) patients reached the operating room and 28 (7%) survived to be admitted to the intensive care unit. Sixteen were eventually discharged from the hospital, but four of these survivors had sustained irreversible cerebral damage. Overall, 12 of 400 (3%) patients survived ED thoracotomy with intact neurologic function. Four factors appeared predictive of poor prognosis. There were no survivors with intact neurologic function among: 150 patients sustaining blunt trauma and arriving in the ED without signs of life (BP, pupil reactivity, respiratory effort); or 87 patients with penetrating torso injuries who had no signs of life at the scene. Following thoracotomy, in the absence of cardiac tamponade, there were no intact survivors of 124 patients without cardiac activity or of aortic occlusion. We believe the above factors should militate against initiating resuscitative thoracotomy in the ED or in deciding to continue heroic measures following thoracotomy.